Va Form 10 0137 Form

Commonly known as a VA Advance Directive, a VA Form 10-0137 is used by the Veterans Health Administration to allow an individual to establish whom they’d like to make important medical decisions on their behalf should something unfortunate happen. In this form, a veteran can specify his or her preferences on how they’d like to be treated in the event that they are unable to make medical decisions on their own. This power can be granted for a short period of time or set up for long term care. By completing a VA Form 10-0137, VA health care providers are aware of the desired preferences for medical care, mental health care, and other types of medical treatment.

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What is a VA Form 10 0137?

A VA Form 10-0137 is used by the Veterans Health Administration (VHA), United States Department of Veterans Affairs. This form is known as a VA Advance Directive: Living Will and Durable Power of Attorney for Health Care. This form will be used in order to allow someone to choose the person who will make decisions for them regarding their health care and describe the preferences for health care treatment, whether it is short-term or long-term.Before filling out this form, consult your medical professional and talk to your loved ones. This will ensure that everyone understands your wishes and is prepared for the changes to your health care. A healthcare professional may also be able to help you fill out the form by suggesting options, helping with information collection, or explaining treatments. This will ensure that your specific wishes are met when it comes to decisions related to your health.

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Most Common Uses

The VA Advance Directive Form is typically used for veterans to write down their specific preferences for health care. This form can be used to name specific people to make health care decision for you, to describe your preferences for how you want to be treated, and so that VA health care providers know your preferences for medical care, mental health care, long-term care, or other types of health care.

Components of a VA Form 10 0137

The VA Form 10-0137 contains the following sections:

Personal Information

Durable Power of Attorney for Health Care

Living Will

Signatures

Signature and Seal of Notary Public

How to complete a VA Form 10 0137 (Step by Step)

Personal Information

Name

Last four digits of SSN

Address

Phone number

Durable Power of Attorney for Health Care - in this section of the Advance Directive Form, you may appoint a specific person to make healthcare decisions for you if you cannot make them for yourself.

Health care agent

Name

Address

Phone number

Alternate health care agent

Living Will

Specific preferences about life-sustaining treatments

Mental health preferences

Additional preferences

How strictly you want your preferences followed

Signatures

Your signature

Witnesses’ signatures, date signed, address - VA facilities employees may be witnesses only if they are members of the Chaplin Service, the Social Work Service, nonclinical employees, or a member of your family.

Signature and Seal of Notary Public

Date

Jurisdiction

Commission expiration

Seal

Paperwork Reduction Act and Privacy Act Information

The U.S. Department of Veterans Affairs requests the information on this form under the authority of 38 C.F.R. §17.32. Possible disclosures include those that are described in the “routine uses” identified in the VA system of records 24VA19, Patient Medical Record-VA, published in the Federal Register in accordance with the Privacy Act of 1974. The OMB Control No. for the form is 2900-0556. Federal agencies may not conduct or sponsor, and a person is not required to respond to a collection of information, unless it displays a current valid OMB control number.